What should I know before and after ESG?

Endoscopic sleeve gastroplasty (ESG) reshapes the stomach from within: an endoscope and a full-thickness suturing device place folds along the stomach’s greater curve, reducing its capacity without surgically removing a section of stomach. A laparoscopic sleeve gastrectomy is different: it removes much of the stomach. ESG is also not an intragastric balloon, which is a separate device-based treatment. The word “sleeve” can obscure these important differences, so ask exactly which procedure is being proposed. [1] [4]

What ESG changes and what it does not

By narrowing and reshaping the stomach, ESG is intended to help reduce food capacity and support weight loss. It is an endoscopic procedure, not the removal of stomach tissue performed in surgical sleeve gastrectomy; it does not use an intragastric balloon. These procedures have different mechanisms, risks, follow-up needs and evidence bases. The studies below evaluate ESG, so their results should not be transferred to surgery or balloons. [1] [4]

ESG is studied as one component of ongoing obesity care. In the MERIT randomised trial, the intervention included a low-calorie diet and physical-activity support, and participants agreed to lifelong dietary restrictions. A procedure alone cannot reproduce that trial’s whole programme. [1]

Who may be considered, and why screening matters

The joint 2024 American Society for Gastrointestinal Endoscopy–European Society of Gastrointestinal Endoscopy guideline suggests endoscopic bariatric and metabolic therapies alongside lifestyle modification for adults with a BMI of at least 30 kg/m², or a BMI of 27.0–29.9 kg/m² with at least one obesity-related condition. It separately suggests endoscopic gastric remodelling, which includes ESG, with lifestyle modification rather than lifestyle modification alone. These are conditional recommendations, not a rule that everyone above a BMI threshold should have ESG. The guideline uses evidence grading; it does not replace an assessment of medical history, goals, prior treatment, procedural risk, preferences and capacity for long-term follow-up. [2]

A 2026 international IFSO consensus similarly supports multidisciplinary evaluation and treats indications, procedural technique and post-procedure management as distinct questions. Its 28 statements were produced by 23 experts through three rounds of anonymous modified-Delphi voting after a structured literature review. It is expert consensus, not a patient trial that establishes one ideal candidate or predicts an individual outcome. [5]

Before proceeding, ask the treating team how it evaluates suitability, what alternatives it considers, and how it handles conditions or medicines that may affect the procedure. Ask who will provide dietary, behavioural and medical follow-up, and how treatment decisions will be revisited if progress is limited. The studies do not provide a universal checklist that can replace an individual clinical assessment.

How to read weight-loss measures

Two percentages commonly appear in ESG research, but they describe different calculations. Percentage total body weight loss (%TBWL) is the weight change divided by a person’s starting weight. Percentage excess weight loss (%EWL) compares the weight lost with the amount above a defined “ideal” weight; MERIT defined ideal weight using a BMI of 25 kg/m². A reported 49% EWL is therefore not the same as losing 49% of starting body weight. Averages also do not show how widely individual results vary. [1]

When comparing results, check the starting population, follow-up point, denominator, missing-data method and whether the percentage is a mean or a threshold reached by a subset. A confidence interval describes uncertainty around an estimated group average; it is not a range that guarantees where an individual’s result will fall.

The MERIT randomised trial: ESG plus support versus support alone

MERIT was a prospective, multicentre randomised trial at nine US centres. It enrolled 209 adults aged 21–65 years with class I or II obesity and assigned 85 to ESG plus lifestyle modification and 124 to lifestyle modification alone, using a 1:1.5 allocation. Lifestyle support included a low-calorie diet and physical activity. The primary endpoint was %EWL at 52 weeks; the trial also reported %TBWL. The comparator was not a sham procedure. [1]

At week 52, mean %EWL was 49.2% (SD 32.0) in the ESG group and 3.2% (SD 18.6) in the lifestyle-only group. Mean %TBWL was 13.6% (SD 8.0) and 0.8% (SD 5.0), respectively. Both comparisons had p<0.0001 in the abstract. A p-value does not quantify how certain an individual person’s benefit is, and the abstract does not provide confidence intervals for these between-group comparisons. [1]

For the threshold of at least 25% EWL at week 52, the abstract reports 59/77 (77%) in the ESG group and 13/110 (12%) in the control group. Those denominators are the analysed participants for this outcome, not the 85 and 124 originally randomised. At week 104, 41/60 (68%) of assessed ESG participants maintained at least 25% EWL. Retightening or crossover was allowed after week 52, so the 104-week result is not a comparison against an unchanged randomised control group. [1]

Three ESG-related serious adverse events were reported among 131 participants (2%). The trial defined its safety population as all participants who underwent ESG, either initially or after crossover, up to week 52; the abstract does not state the SAE ascertainment endpoint alongside this result. The reported safety denominator is not the original 85-person ESG assignment group. The abstract reports no mortality and no need for intensive care or surgery. These figures describe events in this trial, not every possible complication or an individual risk estimate.

Longer follow-up: what cohorts suggest, and what they cannot prove

A prospective, single-centre cohort followed 216 patients treated by one therapeutic endoscopist. Participants had a mean age of 46 years (SD 13) and mean BMI of 39 kg/m² (SD 6); 68% were women. Of the 216, 203, 96 and 68 were eligible for the one-, three- and five-year assessments; complete follow-up among those eligible was 70%, 71% and 82%, respectively. At five years, mean %TBWL was 15.9% (95% CI 11.7–20.5; p<.001); 90% and 61% maintained at least 5% and 10% TBWL, respectively. The five-year estimate concerns the eligible follow-up group, not all 216 people. There was no control group, and results from one centre and one endoscopist may not generalise to every service. [3]

A retrospective multicentre study reported outcomes for 248 patients treated at three centres. Mean baseline age was 44.5 years (SD 10), mean BMI 37.8 kg/m² (SD 5.6), and 73% were women. Mean %TBWL was 15.2% at six months (95% CI 14.2–16.3) and 18.6% at 24 months (95% CI 15.7–21.5). At 24 months, at least 10% TBWL was reported for 84.2% in the per-protocol analysis and 53% in the intention-to-treat analysis. These differ because the analyses handle missing follow-up differently; they should not be presented as equivalent chances for an individual. Five serious adverse events (2%) were reported. The authors state that mild procedural pain, nausea and vomiting not requiring further care were not systematically recorded, so the serious-event count is not a measure of all recovery symptoms. As an uncontrolled retrospective study, it cannot establish comparative effectiveness or cause and effect. [4]

The long-term evidence adds follow-up beyond the randomised trial, but cohort design, loss to follow-up, differences in analysis and specialist-centre settings limit certainty. It supports asking about ongoing support and reassessment; it does not promise a particular amount of weight loss or durability for a new patient.

Recovery, expected symptoms and serious complications

In the 248-patient retrospective cohort, the Spanish site observed patients in hospital after the procedure, whereas US sites discharged patients on the same day. That study described 2–3 weeks of liquid protein shakes, followed by two weeks of puréed food and then a transition to a regular diet. This is one study’s historical care pathway, not a universal protocol or a timetable to follow without clinical advice; practice and individual needs can differ. [4]

Recovery plans should come from the team responsible for the procedure and should cover pain or nausea management, food and fluid progression, medicines, warning symptoms, contact arrangements and follow-up. The trial abstract does not specify a universal sequence of diet stages, exact recovery duration, return-to-work date or safe travel interval. The 2026 consensus identifies post-procedure management as an area for standardisation, so details should be confirmed with the treating team rather than assumed from another person’s experience. [1] [5]

Do not treat all adverse events as routine recovery symptoms. The 248-patient cohort reported five serious events, including collections near the stomach, bleeding requiring transfusion, a pulmonary embolism 72 hours after the procedure, and pneumoperitoneum with pneumothorax requiring a chest tube. These are events reported in that cohort, not a complete list or an estimate of your personal likelihood. Ask for the centre’s written instructions on which symptoms need urgent assessment, where to seek help after discharge and who will coordinate care if you are away from the treating centre. [4]

Questions to take to a clinical consultation

• What about my health history, previous treatments and goals makes ESG suitable or unsuitable for me?
• How does ESG compare with medical treatment, an intragastric balloon or surgical sleeve gastrectomy for my circumstances?
• What outcomes do you measure, at what time points, and how do you handle people who miss follow-up?
• What symptoms are common after the procedure, which require urgent attention, and what number should I call?
• What dietetic, behavioural and medical support will be available after the procedure, for how long, and who provides it?
• How will progress be reviewed, and what options might be discussed if the initial response is below expectations?
• Which parts of the quoted cost cover assessment, procedure and follow-up, and what may be charged separately?
• If I travel for care, who is responsible for post-procedure review and how is urgent care arranged after I return home?

Planning costs and understanding the evidence

For budgeting, compare the endoscopic sleeve gastroplasty cost in Turkey with the assessments and continuing care you expect to need. Request a written breakdown of what is included in a quotation and what may be charged separately.

If you are considering an endoscopic sleeve gastroplasty package, ask the relevant clinical team to confirm in writing what the listing includes and how follow-up is organised. A package listing does not establish that it includes the MERIT trial’s lifestyle programme, a particular recovery protocol or any clinical outcome.

This is an evidence summary, not an individual assessment. Just Clinic Istanbul is an independent marketing and lead-generation platform, not a healthcare provider or medical tourism intermediary. Enquiries may be shared with authorised healthcare partners with your consent. The cited studies cannot determine your suitability, provide a personal risk estimate or set the recovery plan for your case.

References

1. Abu Dayyeh BK, Bazerbachi F, Vargas EJ, Sharaiha RZ, Thompson CC, Thaemert BC, Teixeira AF, Chapman CG, Kumbhari V, Ujiki MB, Ahrens J, Day C, MERIT Study Group, Galvao Neto M, Zundel N, Wilson EB, Acosta AJ, Badurdeen D, Buttar N, Clark MM, Eaton L, Ghanem O, Grothe K, Jirapinyo P, Kellogg T, Klein CL, Mundi M, Storm AC, Rivera AR, Wilson TD. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. The Lancet. 2022;400(10350):441–451. First published online 28 July 2022; issue publication 6 August 2022. doi:10.1016/S0140-6736(22)01280-6. PMID 35908555.
2. Jirapinyo P, Hadefi A, Thompson CC, Patai ÁV, Pannala R, Goelder SK, Kushnir V, Barthet M, Apovian CM, Boskoski I, Chapman CG, Davidson P, Donatelli G, Kumbhari V, Hayee B, Esker J, Hucl T, Pryor AD, Maselli R, Schulman AR, Pattou F, Zelber-Sagi S, Bain PA, Durieux V, Triantafyllou K, Thosani N, Huberty V, Sullivan S. American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity. Gastrointestinal Endoscopy. 2024;99(6):867–885.e64. First published online 19 April 2024; issue publication June 2024. doi:10.1016/j.gie.2023.12.004. PMID 38639680. Erratum: Gastrointestinal Endoscopy. 2025;102(4):626. doi:10.1016/j.gie.2024.10.026; PMID 40728484.
3. Sharaiha RZ, Hajifathalian K, Kumar R, Saunders K, Mehta A, Ang B, Skaf D, Shah S, Herr A, Igel L, Dawod Q, Dawod E, Sampath K, Carr-Locke D, Brown R, Cohen D, Dannenberg AJ, Mahadev S, Shukla A, Aronne LJ. Five-Year Outcomes of Endoscopic Sleeve Gastroplasty for the Treatment of Obesity. Clinical Gastroenterology and Hepatology. 2021;19(5):1051–1057.e2. First published online 1 October 2020; issue publication May 2021. doi:10.1016/j.cgh.2020.09.055. PMID 33011292.
4. Lopez-Nava G, Sharaiha RZ, Vargas EJ, Bazerbachi F, Galvao Neto M, Bautista-Castaño I, Acosta A, Topazian MD, Mundi MS, Kumta N, Kahaleh M, Herr AM, Shukla A, Aronne L, Gostout CJ, Abu Dayyeh BK. Endoscopic Sleeve Gastroplasty for Obesity: a Multicenter Study of 248 Patients with 24 Months Follow-Up. Obesity Surgery. 2017;27(10):2649–2655. Issue publication October 2017; no online publication date was reported in the checked PubMed record. doi:10.1007/s11695-017-2693-7. PMID 28451929.
5. Cohen RV, Ponce J, Abu Dayyeh B, Stier C, Levinson R, Salminen P, Prager G. The International Federation for Surgery and Other Therapies for Obesity (IFSO) Consensus on Clinical Practice in Endoscopic Sleeve Gastroplasty. Obesity Surgery. 2026;36(4):1444–1449. First published online 5 March 2026; issue publication April 2026. doi:10.1007/s11695-026-08518-3. PMID 41784726.